Various techniques and drug regimes for thoracic paravertebral block (PVB) have been evaluated for post-thoracotomy analgesia, but there is no consensus on which technique or drug regime is best. We have systematically reviewed the efficacy and safety of different techniques for PVB. Our primary aim was to determine whether local anaesthetic (LA) dose influences the quality of analgesia from PVB. Secondary aims were to determine whether choice of LA agent, continuous infusion, adjuvants, pre-emptive PVB, or addition of patient-controlled opioids improve analgesia. Indirect comparisons between treatment arms of different trials were made using metaregression. Twenty-five trials suitable for metaregression were identified, with a total of 763 patients. The use of higher doses of bupivacaine (890–990 mg per 24 h compared with 325–472.5 mg per 24 h) was found to predict lower pain scores at all time points up to 48 h after operation (P=0.006 at 8 h, P=0.001 at 24 h, and P<0.001 at 48 h). The effect-size estimates amount to around a 50% decrease in postoperative pain scores. Higher dose bupivacaine PVB was also predictive of faster recovery of pulmonary function by 72 h (effect-size estimate 20.1% more improvement in FEV1, 95% CI 2.08%–38.07%, P=0.029). Continuous infusions of LA predicted lower pain scores compared with intermittent boluses (P=0.04 at 8 h, P=0.003 at 24 h, and P<0.001 at 48 h). The use of adjuvant clonidine or fentanyl, pre-emptive PVB, and the addition of patient-controlled opioids to PVB did not improve analgesia. Further well-designed trials of different PVB dosage and drug regimes are needed.

Background: In order to assess the short term risks of pneumonectomy for lung cancer in
contemporary practice a one year prospective observational study of pneumonectomy outcome
was made. Current UK practice for pneumonectomy was observed to note patient and treatment
factors associated with major complications.
Methods: A multicentre, prospective, observational cohort study was performed. All 35 UK
thoracic surgical centres were invited to submit data to the study. All adult patients undergoing
pneumonectomy for lung cancer between 1 January and 31 December 2005 were included. Patients
undergoing pleuropneumonectomy, extended pneumonectomy, completion pneumonectomy
following previous lobectomy and pneumonectomy for benign disease, were excluded from the
study.
The main outcome measure was suffering a major complication. Major complications were defined
as: death within 30 days of surgery; treated cardiac arrhythmia or hypotension; unplanned intensive
care admission; further surgery or inotrope usage.
Results: 312 pneumonectomies from 28 participating centres were entered. The major
complication incidence was: 30-day mortality 5.4%; treated cardiac arrhythmia 19.9%; unplanned
intensive care unit admission 9.3%; further surgery 4.8%; inotrope usage 3.5%. Age, American
Society of Anesthesiologists physical status ≥ P3, pre-operative diffusing capacity for carbon
monoxide (DLCO) and epidural analgesia were collectively the strongest risk factors for major
complications. Major complications prolonged median hospital stay by 2 days.
Conclusion: The 30 day mortality rate was less than 8%, in agreement with the British Thoracic
Society guidelines. Pneumonectomy was associated with a high rate of major complications. Age,
ASA physical status, DLCO and epidural analgesia appeared collectively most associated with major complications

The effect of intermittent positive airway pressure to the non-ventilated lung was assessed in 10 patients who
desaturated during one-lung ventilation. Once their saturation fell below 95% they were given a slow inflation of
2 l/min of oxygen into the non-ventilated lung for two seconds. This was repeated every 10 seconds for five minutes
or until the saturation rose to 98%, whichever was sooner. The initial mean SpO2 was 89.3%±4.2%. All 10
patients had an increase in saturation. The mean saturation following intermittent positive airway pressure was
96.5%±1.6% (P <0.0001). Similarly, the mean oxygen tension rose from 67.2±12.8 mmHg to 98.9±19.8 mmHg. Intermittent positive airway pressure should be considered for patients who desaturate while undergoing one-lung ventilation.

Background: Although one-lung ventilation (OLV) has become
an established procedure during thoracic surgery, sparse
data exist about inflammatory alterations in the deflated, reventilated
lung. The aim of this study was to prospectively investigate
the effect of OLV on the pulmonary inflammatory response
and to assess possible immunomodulatory effects of the anesthetics
propofol and sevoflurane.
Methods: Fifty-four adults undergoing thoracic surgery with
OLV were randomly assigned to receive either anesthesia with
intravenously applied propofol or the volatile anesthetic
sevoflurane. A bronchoalveolar lavage was performed before
and after OLV on the lung side undergoing surgery. Inflammatory
mediators (tumor necrosis factor
, interleukin 1, interleukin
6, interleukin 8, monocyte chemoattractant protein 1)
and cells were analyzed in lavage fluid as the primary endpoint.
The clinical outcome determined by postoperative adverse
events was assessed as the secondary endpoint.
Results: The increase of inflammatory mediators on OLV was
significantly less pronounced in the sevoflurane group. No difference
in neutrophil recruitment was found between the
groups. A positive correlation between neutrophils and mediators
was demonstrated in the propofol group, whereas this
correlation was missing in the sevoflurane group. The number
of composite adverse events was significantly lower in the
sevoflurane group.
Conclusions: This prospective, randomized clinical study
suggests an immunomodulatory role for the volatile anesthetic
sevoflurane in patients undergoing OLV for thoracic surgery
with significant reduction of inflammatory mediators and asignificantly better clinical outcome (defined by postoperative adverse events) during sevoflurane anesthesia.

Background. Primary graft dysfunction (PGD) is a predominant cause of early morbidity and
mortality after lung transplantation. Although substantial work has been done to understand risk factors for PGD in terms of donor, recipient, and surgical factors, little is understood regarding the potential role of anaesthetic management variables in its development.
Methods. We conducted a retrospective exploratory analysis of 107 consecutive lung transplants to determine if anaesthesia factors were associated with early graft function quantified by PaO2/FIO2. Multivariate regression techniques were used to explore the association between anaesthetic management variables and PaO2/FIO2 ratio 12 h after operation. The relationship between these variables and both time to tracheal extubation and intensive care unit (ICU) length of stay was further examined using the Cox proportional hazards.
Results. On multivariate analysis, increasing volume of intraoperative colloid, comprising predominantly Gelofusinew (succinylated gelatin), was independently associated with a lower PaO2/FIO2 12 h post-transplantation [b coefficient 242 mm Hg, 95% confidence interval (CI) 27 to 277 mm Hg, P¼0.02] and reduced rate of extubation [hazard ratio (HR) 0.65, 95% CI 0.49–0.84, P¼0.001]. There was a trend for intraoperative colloid to be associated with a reduced rate of ICU discharge (HR 0.79, 95% CI 0.31–1.02, P¼0.07).
Conclusions. We observed an inverse relationship between volume of intraoperative colloid
and early lung allograft function. The association persists, despite detailed sensitivity analyses and adjustment for potential confounding variables. Further studies are required to confirm these findings and explore potential mechanisms through which these associations may act.

BACKGROUND: There is no consensus on the best technique for lung isolation for thoracic surgery. In this study, we compared the clinical performance of three bronchial blockers (BBs) available in North America with left-sided double-lumen tubes (DLTs) for lung isolation in patients undergoing left-sided thoracic surgery.

METHODS: One hundred four patients undergoing left-sided thoracotomy or video-assisted thoracoscopic surgery were randomly assigned to one of the four lung isolation groups (n = 26/group). Lung isolation was with an Arndt(R) wire-guided BB (Cook(R) Critical Care, Bloomington, IN), a Cohen Flexi-tip(R) BB (Cook Critical Care) or a Fuji Uni-blocker(R) (Fuji Systems, Tokyo) or with a left-sided DLT (Mallinckrodt Medical, Cornamadde, Athlone, Westmeath, Ireland). Anesthetic management and lung isolation were performed according to a standardized protocol. Each group was randomly subdivided into two subgroups (n = 13/subgroup): immediate suction (at the time of insertion of the lung isolation device) (Subgroup I) or delayed suction (20 min after insertion of the lung separation device) (Subgroup D) according to when suction was applied to the BB suction channel or the bronchial lumen of the DLT. Using a verbal analog scale, lung collapse was assessed by the surgeons, who were blinded to the lung isolation technique.

RESULTS: There was no difference among the lung isolation devices in lung collapse scores at 0 (P = 0.66), 10 (P = 0.78), or 20 min (P = 0.51) after pleural opening. The time to initial lung isolation was less for DLTs (93 +/- 62 s) than BBs (203 +/- 132) (P = 0.0001). There were no differences among the BBs in the time to lung isolation (P = 0.78). There were significantly more repositions after initial placement of the lung isolation device with BBs (35 incidents) than with DLTs (two incidents) (P = 0.009). The Arndt BB required repositioning more frequently (16 incidents) than the Cohen BB (8) or the Fuji BB (11) (P = 0.032).

CONCLUSIONS: The three BBs provided equivalent surgical exposure to left-sided DLTs during left-sided open or video-assisted thoracoscopic surgery thoracic procedures. BBs required longer to position and required intraoperative repositioning more often. The Arndt BB needed to be repositioned more often than the other BBs.

AB BACKGROUND: Collapse of the ipsilateral lung facilitates surgical exposure during thoracic procedures. The use of different gas mixtures during two-lung ventilation (2LV) may improve or impede surgical conditions during subsequent one-lung ventilation (OLV) by increasing or delaying lung collapse. We investigated the effects of three different gas mixtures during 2LV on lung collapse and oxygenation during subsequent OLV: Air/Oxygen (fraction of inspired oxygen [Fio2] = 0.4), Nitrous Oxide/Oxygen (“N2O,” Fio2 = 0.4) and Oxygen (“O2,” Fio2 = 1.0). METHODS: Subjects were randomized into three groups: Air/Oxygen (n = 33), N2O (n = 34) or O2 (n = 33) and received the designated gas mixture during induction and until the start of OLV. Subjects’ lungs in all groups were then ventilated with Fio2 = 1.0 during OLV. The surgeons, who were blinded to the randomization, evaluated the lung deflation using a verbal rating scale at 10 and 20 min after the start of OLV. Serial arterial blood gases were performed before anesthesia induction, during 2LV, and every 5 min, for 30 min, after initiation of OLV. RESULTS: The use of air in the inspired gas mixture during 2LV led to delayed lung deflation during OLV, whereas N2O improved lung collapse. Arterial oxygenation was significantly improved in the O2 group only for the first 10 min of OLV, after which there were no differences in mean Pao2 values among groups. CONCLUSIONS: De-nitrogenation of the lung during 2LV is a useful strategy to improve surgical conditions during OLV. The use of Fio2 1.0 or N2O/O2 (Fio2 0.4) during 2LV did not have an adverse effect on subsequent oxygenation during OLV. (C) 2009 by International Anesthesia Research Society.

WE present two cases of the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) during resection of obstructing tracheal papillomata. Conventional anesthesia techniques may be unsafe with near obstructing papillomatous disease of the trachea. The advantage of ECMO in this circumstance is that gas exchange can be totally supported for the duration of the procedure while at the same time providing an apneic unobstructed surgical field. There are reports of the use of ECMO during surgery for tracheal obstruction and resection in neonates and children but to our knowledge this is the first account of its use in adults.

OBJECTIVE: Acute respiratory distress syndrome (ARDS) is a major cause of death following lung resection. At this institution we reported an incidence of 3.2% and a mortality of 72.2% in a review of patients who underwent pulmonary resection from 1991 to 1997 [Kutlu C, Williams E, Evans E, Pastorino U, Goldstraw P. Acute lung injury and acute respiratory distress syndrome after pulmonary resection. Ann Thorac Surg 2000;69:376-80]. The current study compares our recent experience with this historical data to assess if improved recognition of ARDS and treatment strategies has had an impact on the incidence and mortality. METHODS: We identified and studied all patients who developed ARDS following a lung resection of any magnitude between 2000 and 2005 using the 1994 consensus definition: characteristic chest X-ray or CT, PaO2/FiO2 < 200 mmHg, pulmonary capillary wedge pressure < 18 mmHg and clinical acute onset. Overall incidence and mortality were recorded. Univariate analyses (t-test or chi(2), as appropriate) were carried out to identify correlations between pre-, peri- and postoperative variables and outcomes. RESULTS: We performed 1376 lung resections during the study period. Of these 705 (51.2%) were for lung cancer and 671 (48.8%) for other diseases. Twenty-two patients fulfilled the criteria for ARDS with 10 deaths in this group. The incidence and mortality from ARDS had fallen significantly over the two study periods (incidence from 3.2% to 1.6%, p=0.01; mortality from 72% to 45%, p=0.05). Although no significant correlations with incidence and mortality were identified, we found a number of significant trends. In keeping with the ARDS network study recommendations, postoperative tidal volumes were maintained at a lower level when a higher number of pulmonary segments were excised (p=0.001). Furthermore, consistent with findings in previous studies, the highest incidence and death from ARDS were in pneumonectomy patients (incidence 11.4%; mortality 50%). Although the incidence and mortality from ARDS following pneumonectomy were not significantly different between the two study periods (p=0.08, p=0.35), we found that fewer pneumonectomies were performed in the later period (pneumonectomy rate of 6.4% vs 17.4%). CONCLUSIONS: The incidence and mortality of ARDS have decreased in our institution. We postulate that this is due to more aggressive strategies to avoid pneumonectomy, greater attention to protective ventilation strategies during surgery and to the improved ICU management of ARDS.

We present a simple and reliable airway assembly that can be used to provide lung isolation for lung lavage or other such procedures in small children. Essentially, two tracheal tubes are passed through the glottis, one seated endobronchially to isolate the lung to be lavaged and the second seated in the trachea. This assembly mimics commercially available double lumen bronchial tubes, considered by many to be the airway device of choice for lung isolation. The obvious advantages of this technique include effective lung isolation, the ability to collect lavage returns by gravity instead of suction, and the option of differential lung ventilation after lavage. In addition, the patient can be kept in the supine position, and fiberoptic bronchoscopy can be used to periodically ensure continued lung isolation throughout the procedure.